Ms Lord Ellison

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 You are a Public health nurse in Boomsgrave health centre in Walsgrave CV2 4HF

Patient Name:      Mr Lord Ellison

DOB:                       20/04/1976

Address:               36, New Avenue road

                               Marcion

                               CH2 3 DP

Occupation:         builder since 10 years

History:                Regular patient in Boomsgrave health centre in Walsgrave CV2 4HF

                               occasionally present with lower back pain and takes anti-inflammatory

                               had spinal x-ray 2 years ago – some narrowing of L3- 4, signs of osteoarthritis

                               type -II DM controlled by diet and exercise

18/03/2018

                              Sudden onset of lower back pain while working.radiating to left side and then to the down          

                               left thigh. Took ibuprofen which settled pain but worse this morning. 

                               Didn’t go for work due to the pain.

                              Tenderness around the lower spine, walks slowly.SLR positive on left side at 45

                               degree.normal strength on both legs.pain inhibiting flexion and extension.

Assessment:     possible disc prolapse

Treatment:       Proper bed rest -3 days,paracetamol; 1 g, NSAIDs, hot water bottle on back, follow -up in 3 days.

21/03/2018

                             no change, neuro obs – normal

                             complaints of pain but no worsening

Assessment:   No change in symptoms

Treatment:     Continue treatment as before.NSAIDs increased to 4x daily, follow up visit after 3 days.

24/03/2018

                            Back pain, radiating pain in legs, especially at night. urine test- glycosuria 2 plus(NAD)

                            walk slowly, difficulty in movement, Random blood glucose-14 mmol

Assessment:  symptoms worse .inactivity making diabetes symptoms worse

Treatment:     Codeïne phosphate 30-60 mg x 4 hourly.diet modification recommended- diabetes

27/03 /2018

                            Urgent visit to the patient’s home. Pain increased overnight in the back and left leg. Pain

                            uncontrollable by oral medication.numbness on the left leg.

                            Unable to get out of bed.no ankle reflexes, decreased toe extension, pinprick sensation

                            decreased. blood glucose- 16 mmol

 

Assessment:  uncontrollable y medication.? for nerve root compression and disc prolapse

Treatment:    Arranged ambulance transport to Watford hospital emergency department, arranged an

                           orthopaedic assessment through phone.

 

Write a letter to Dr Koshy Sandik, Watford Hospital, Watford, Cv2 4DX

 

 

27/03/2018

Dr Koshy Sandik
Watford Hospital
Watford
Cv2 4 DX

Dear Dr Sandik

Re: Mr Lord Ellison, DOB: 20/04/1976

I am writing to transfer Mr Ellison to your facility for urgent hospitalisation and further orthopaedic assessment since he is suspected to have nerve root compression and disc prolapse.

Mr Ellison is a builder who has had narrowing of L3-4 and signs of osteoarthritis for two years, and his occasional back pain was managed conservatively. On 18/03/2018, he presented with sudden onset of severe back pain on his left side, which was radiated down to the back of the left thigh. On assessment, he had symptoms suggestive of the above-mentioned condition, and he was treated with symptomatically.

Last three days of consecutive visits showed that Mr Ellison had no change in his pain; however, it is not worse. He had difficulty in movement and walked slowly. He was received the same medication with an increased frequency of anti-inflammatory. In addition, he was recommended for diet modification since his inactivity leads to worse diabetic symptoms.

Today, Mr Ellison was visited urgently because his affected leg became numb, confined to bed, and the pain was uncontrolled by the prescribed medications. Examination revealed that decreased toe extension and decreased pinprick sensation with no ankle reflexes. Along with that, his blood glucose level increased to 16 mmol.

In view of the above, kindly provide immediate evaluation and intervention at the earliest.

Please contact me for further queries.

Yours sincerely

Public Health Nurse
Boomsgrave health centre
Walsgrave
CV2 4HF

 

 

 

 

 

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